Transcript Document

Cancer research in the
Midland Region – the
prostate and bowel cancer
projects
Ross Lawrenson
Waikato Clinical School
University of Auckland
MoH/HRC Cancer Research agenda
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Lung cancer
Palliative care
Prostate Cancer
Bowel Cancer
Cancer Control New Zealand
• Initiatives to reduce the mortality from cancer
• Initiatives to reduce the impact of cancer
• Initiatives to reduce inequalities in access to
cancer services due to ethnicity, economic
status, and place of domicile
• How effectively new initiatives have been
implemented.
Prostate Cancer RFP
• Research will provide a description of the
types of care received by men and
demonstrate the equity issues, costs and
complications arising from this care.
• The research will also provide details of the
proportion of men who are likely to undergo a
biopsy after a PSA test
Our proposal
• Look at PSA testing in general practice
• Look at differences between Maori and nonMaori and urban and rural patients using
national data
• Look at pathways of care for a cohort of men
(500) diagnosed with prostate cancer
• Look at the costs and complications of
treatment for prostate cancer in a sample of
100 men including approx 50 Maori.
Natural history
• Prostate cancer is a slowly growing tumour that occurs in
old age.
• Most cancers have an indolent course during the first 10
to 15 years.
• Johansson (1997) showed that in a population-based
cohort of men with prostate cancer after 15 years of follow
up, 80% of men who had initially presented with localised
disease were alive and survival was unaffected by
whether or not they had received treatment.
• Further follow up at 15 to 20 years revealed a substantial
decrease in cumulative progression-free survival.
ERSPC and PLCO
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Early evidence from two large randomised controlled trials of prostate
cancer screening, European Randomized Study of Screening for
Prostate Cancer (ERSPC) and the U.S. Prostate, Lung, Colorectal, and
Ovarian (PLCO), was published in March 2009. The trials analysed
men from ages 55 to 69 years, and 55 to 74 years, respectively.
The European trial reported a significant absolute risk difference
between the screening and control groups of 0.71 prostate cancer
deaths per 1000 men.
This means that 1410 men would have to be screened 1.7 times over 9
years (number needed to screen), and 48 men would need to be
treated (number needed to treat) to prevent one prostate cancer death.
The US study found no benefit.
Both the European and U.S. trials reported significant harms
associated with infection, urinary incontinence and impotence
Goteborg study
• From 1994 to 2008, from an eligible population of 32298, a
cohort of 20,000 men aged 50-64 years with no prostate
cancer was randomly assigned to either a group that was
invited every two years for PSA screening (n=9952) or to a
control group that was not offered PSA screening (n=9952).
• At the beginning of the study period, the PSA threshold used
for diagnosing prostate cancer was 3.0 ng/mL of blood. For
consistency with the European trial, in 1999 the diagnostic
cut-off was changed to 2.9 ng/mL and in 2005 it was changed
again to 2.4 ng/mL to reflect recalibration of the PSA-assay.
• Results:
• In the screening group, the participation rate in at least one
screening round was 76% (n=7578) and a total of 29315 PSA
tests were performed.
• A total of 4693 positive PSA results were recorded. 33% of
the participants (n= 2469) received at least one positive
result and 93% of these (n=2298) had a biopsy performed. Of
the enrolled men, 78% (n=15501) reached the maximum
follow-up time of 14 years.
Goteborg study
• After 14 years of follow-up, within a core age group of
50 to 64 years, 44 and 78 prostate cancer deaths were
observed in the screening group and control groups
respectively. The unadjusted rate ratio for death from
prostate cancer in the screening group was 0.56 (95%
CI, 0.39-0.82 p=0.002).
• This corresponds with a significant absolute risk
difference between groups of four deaths per 1000 men.
• The incidence of prostate cancer was almost 60%
greater in the screened group (see table) .
• The all cause mortality in the two groups was 1982 in
the control group and 1981 in the screened group.
Goteborg study
Control Group
Screened Group
Number with
prostate cancer
718
1138
Number of prostate
cancer deaths
78
44
Number with
prostate cancer who
died of unrelated
causes
54
109
Treatment or intervention
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Options for treatment include radical prostatectomy, radiotherapy
(focussed beam, or brachytherapy), or watchful waiting.
We have evidence from an RCT of radical prostatectomy versus
watchful waiting - fewer men in the radical prostatectomy group died of
prostate cancer (30 vs. 50, P=0.01) (Bill-Axelson et al 2005).
The benefit was seen mostly in men younger than 65 years.
There is little convincing evidence that brachytherapy or focussed
beam radiotherapy have different survival outcomes than
prostatectomy.
Treatment options in New Zealand vary from DHB to DHB and
differences in outcomes of the various options have not been evaluated
in the local setting.
Harm of treatment
• Treatment commonly causes moderate-to-substantial harms,
such as erectile dysfunction, urinary incontinence, bowel
dysfunction and on occasion death.
• A study by Gore (2009) found 2 years post treatment around
20% of men suffered from urinary incontinence, 60% suffered
from erectile dysfunction and 10-15% suffered from problems
with bowel function.
• Urinary incontinence was more common after prostatectomy.
• Bowel dysfunction was more common after radiation therapy.
• All three modalities profoundly affect sexual function.
• These harms are important because some men with prostate
cancer who are treated may never have developed symptoms
related to cancer during their lifetime.
Consideration of cost
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Screening large numbers of people is expensive and can divert both
human and financial resources from other health services.
The costs of screening for prostate cancer include:
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GP time in counselling men about the benefits and risks
the cost of the test
the cost of diagnosis with prostatic biopsy,
the pathology costs needed to make the diagnosis,
the cost of counselling for those men who treatment is being suggested,
the costs of surgery or radiotherapy (or watchful waiting).
These costs need to be balanced against the cost of investigating and
treating symptomatic patients.
Ideally, a cost-effectiveness analysis should be undertaken before any
screening program is considered.
Prostate Cancer
Ethnicity
PSA testing in NZ
• 33 percent of men over
50 years of age had a
PSA test in 2007
• 54 percent over 50 years
had a test at some stage
over the three-year
period from 2005 to
2007.
• 40% of men aged 65-74
had a test over a oneyear period and
approximately 60% of
men in this age group
have had a test over a
three year period.
PSA testing in GP
• We know that testing is being carried out
• Don’t know who is driver of this testing – GP
or patient?
• Don’t know what GPs do when find a raised
PSA
• Don’t know whether differences in access to
screening eg for Maori or rural patients
Study 1 – PSA test
• Recruit 20 practices across the Midland
Network
• Half rural, half with good proportion of Maori
• Identify all men aged over 40 years
• Find proportion with a PSA test in 2010
• Look at results and audit referral patterns and
biopsy rates
• Compare, rural/urban and Maori to non-Maori
Study 2 - Review national data
• Good data on Māori already published
• Not so good info on urban rural differences or
by region for last 15 years 1994 -2009
• Will follow similar study to our study on breast
cancer
• Will also look at cause of death
Study 3 pathways of care
• Approx 350 men diagnosed in Midland region
with prostate cancer each year
• Want to establish path from presentation to
GP, referral to specialist, diagnosis, treatment
options and follow up
• Particular interest is subset who have been
diagnosed through screening
• Will try and look at variations by age, social
class ethnicity and domicile
Study 4 – costs and complications
• Potential benefit of screening have been
highlighted by ERSPC and Goteborg study
• Complications of treatment are well
recognised.
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Urinary incontinence
Bowel dysfunction
Erectile dysfunction
Infection
• Other less well recorded
– Depression
– Social/family impact
Costs
• Costs incurred following diagnosis
• Costs incurred by doing a PSA test
Time frame
• Three project
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Currently undergoing study 1
Study 2 will begin later this year
Study 3 will begin in 2012
Study 4 will also begin later in 2012
Bowel Cancer – the Auckland Study
PI Prof M. Findlay
Bowel Cancer
• Bowel cancer is the most common cancer in New
Zealand and we have one of the highest death rates
from bowel cancer in the developed world.
• There are approximately 1200 deaths each year and
about 2700 new cases of bowel cancer each year.
• In May 2008 the Minister of Health announced that a
New Zealand bowel cancer screening programme
would be established.
Maori
• There are clear inequalities in bowel cancer between
Māori and non-Māori.
• Evidence shows that Māori are less likely to be
diagnosed, and more likely to die from bowel cancer.
Colorectal
Aims and/or hypothesis
• Look at urban/rural disparities as well as
socioeconomic and ethnicity factors in the
management of colorectal cancer patients following
diagnosis across New Zealand
• Hypothesis that rural patients have inferior access
to timely and appropriate treatment options and
therefore worse outcomes.
• The aim of the project is to use Key Performance
Indicators (KPIs) of service delivery to identify
differences in the management of urban and rural
patients, and through formation of a national
advisory group develop recommendations for
service change that can later be used to assess
improvement.
Proposed methodology
• A national cohort of all patients that had a colorectal
cancer diagnosis during years 1 January 2007-31
December 2008 as identified by the New Zealand
Cancer Registry (we expect approximately 5600 cases).
• Data will be extracted from hospital systems and patient
medical records. (With help of Cancer Networks)
• Data will be used to calculate the proportion of patients
meeting each KPI.
• Differences in KPIs by rurality, socioeconomic status
(NZDep1) and ethnicity will be examined. Factors
predictive of short-term (3-year) survival and diseasefree survival will be examined.
Indicators to be collected from medical
records
Comparisons
Site: Colon
Site: Rectal
Rural/urban
Etnicity
Social
deprivation
Presentation:
acute vs. non-acute
Presentation:
acute vs. non-acute
Stage at diagnosis (TNM):
Stage at diagnosis (TNM):
Staging process
Staging process
Treatment
Surgical procedure
adjuvant chemotherapy
undergoing resection of secondaries
review at an MDM
participation in a clinical trial
Treatment
Surgical procedure
adjuvant chemotherapy
undergoing resection of secondaries
review at an MDM
participation in a clinical trial
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Management
median time referral receipt to diagnosis
median time diagnosis to treatment
median time to initiation of adjuvant
treatment
Management
median time referral receipt to
diagnosis
median time diagnosis to treatment
median time to initiation of adjuvant
treatment
Outcomes
progression free survival at 3 years
% alive and stoma-free at 3 years
Outcomes
progression free survival at 3 years
% alive and stoma-free at 3 years
Additional work
• To ensure explanatory power for Māori and
Pacific an additional cohort using a further 4
years of data will be collected.
Summary
• Data on management of cancer is essential to
improving treatment and outcomes for people
with cancer.
• Midland Regional Cancer Network is essential
to helping explore inequalities particularly with
regards rural patients and for Maori